FORM 1 [ See Rule 5 (2) ] APPLICATION -CUM-DECLARATION AS TO PHYSICAL FITNESS 1. Name of the applicant ............................................................. 2. Son/wife/daughter of ............................................................. 3. Permanent address ............................................................. 4. Temporary address ............................................................. Official address (if any) ............................................................. 5. (a) Date of birth ............................................................. (b) Age on date of application ............................................................. 6. Identification marks (1) ............................................................ (2) ............................................................ Declaration, (a) Do you suffer from epilepsy or from sudden attacks ................................................................... of loss of consciousness or giddiness from any cause? (b) Are you able to distinguish with each eye (or if you have held a driving licence to drive a motor vehicle for a period of not less than five years and if you have lost the sight of one eye after the said period of five years and if the application is for driving a light motor vehicle other than a transport ve hicle fitted with an outside mirror on the steering wheel side) or with one eye, at a distance of 25 metres in good day light with glasses, if worm a motor car number plate? Yes/No (c) Have you lost either hand of foot or are you suffering from any defect of muscular power of either arm or leg? Yes/No (d) Can you readily distinguish the pigmentary colours, red and green? Yes/No (e) Do you suffer from night blindness? Yes/No (f) Are you so deaf so as to be unable to hear (and if the application is for driving a light motor vehicle, with or with out hearing aid) the ordinary sound signal? Yes/No (g) Do you suffer from any other disease or disability likely to cause your driving of a motor vehicle to be a source of danger to the public, if so, give details. Yes/No I herehy declare that to the best of my knowledge and belief, the particulars given above and the declaration made therein are true. (Signature or thumb impression of the Applicant) NOTES.-(1) An applicant who answers "Yes" to any of the questions (a), (c), (e), (f) and (g) or "No" to either of the questions (b) and (s) should amplify his answers with full particulars, and may be required to give further information relating thereto. (2) This declaration is to be submitted invariably with medical certificate in Form IA. Downloaded from www.barrackpore.gov.in, the official website of Barrackpore Sub-Division
